Emergency medicine
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7343.958 (Published 20 April 2002) Cite this as: BMJ 2002;324:958
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The responses by Condon, Poolman et al, and Cooke reinforce the
international nature of the problem of emergency department overcrowding.1
In particular, I support the comment by Cooke, that “excessively high bed
occupancy (over 85%) is not a sign of efficient management but a sign of
failure to plan.” Derlet has stated that “should there be a major
infectious disease epidemic or national catastrophe, EDs and hospitals
could not accommodate the demand.”2
Cooke is correct in stating that the solutions require a whole of
system response.However, he states that I only suggested two long term
measures to address overcrowding. The text clearly states that all the
causes of overcrowding outlined in box 1 need to be addressed. As stated
in the methods, due to space restrictions, it is simply not possible to
provide a comprehensive review.
Cooke also states that an extra 10000 beds are required in England to
help decrease overcrowding, with the aim of keeping bed occupancy at 82-
85%. This reinforces the finding that emergency department overcrowding is
due to increased demand and decreased capacity.2 The data from Poolman et
al on the prolonged times required for organising admission of patients,
highlights the congestion of the acute hospital system. It also reinforces
the loss of clinical productivity and effectiveness for doctors who are
involved with organising patient disposition.
Wilson suggests a number of strategies including an after hours
general practice on the hospital site. My only concern with this is that
it sends a clear message to the community to attend the hospital with
their problem, thus potentially aggravating the situation. The focus
should be to use community-based resources as much as possible.
I agree with the comments by Nolan et al. The decision to have the
resuscitation algorithm “adapted from the Resuscitation Council (UK)
website” was an editorial one. The reference for the algorithm came from
reference 6 in the paper, and this is what was originally submitted. The
other “adaptations” he refers to relate to the same editorial decision.
These “adaptations” reflect the American Heart Association algorithm.3 I
agree with their comments on vasopressin, and the reference he quotes to
support this is the same as reference 7 in my paper. Whilst I do not use
vasopressin in my practice, the comments in my paper that “vasopressin is
included as an option in the [American Heart Association] algorithm”
nevertheless reflects that algorithm.
REFERENCES
1. Fatovich DM. Recent developments: emergency medicine. BMJ
2002;324:958-962
2. Derlet RW. Overcrowding in emergency departments: increased demand
and decreased capacity. [editorial] Ann Emerg Med 2002;39:430-432
3. International Guidelines 2000 Conference on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation 2000;102
(Suppl 1):1-384
Competing interests: No competing interests
Editor – We are concerned about the resuscitation algorithm displayed
in Fatovich’s recent review on emergency medicine.1 The legend below the
algorithm indicates that it was “adapted from the Resuscitation Council
(UK) website”. We wish to make it very clear that these modifications are
not consistent with the RC (UK) and European Resuscitation Council (ERC)
guidelines for advanced life support (ALS) and the changes to the
algorithm were made without approval by either of these organisations. The
publication of this modified algorithm in a prominent British journal will
confuse European healthcare professionals and detracts from the consistent
educational approach we strive to achieve on the RC (UK) and ERC ALS
course. The algorithm displayed in Fatovich’s review is the one published
in the International Guidelines 2000 for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care.2 The correct ERC and RC (UK) universal ALS
algorithm is displayed at www.resus.org.uk/pages/alsalgo.pdf
Vasopressin is not included in the ERC and RC (UK) ALS guidelines.3
This decision was made by the ALS Working Group of the ERC after careful
consideration of the scientific evidence and economic consequences of
including vasopressin in the guidelines. A recent randomised controlled
trial demonstrating no benefit from vasopressin after in-hospital cardiac
arrest provides further support for this decision.4 The results of a
European multicentre prospective randomised trial comparing vasopressin
with adrenaline in prehospital cardiac arrest will be available soon (V.
Wenzel, personal communication). Any role for vasopressin in the ERC and
RC (UK) ALS guidelines will be reconsidered at this stage.
Other “adaptations” to the algorithm made by Fatovich include changes
to the list of potentially reversible causes and to the wording of the
interventions to be considered “during CPR”.
References
1. Fatovich DM. Emergency medicine. BMJ 2002; 324: 958-62.
2. American Heart Association in collaboration with the International
Liaison Committee on Resuscitation (ILCOR). International Guidelines 2000
for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – A
Consensus on Science. Resuscitation 2000; 46:1-448.
3. De Latorre F, Nolan J, Robertson C, Chamberlain D, Baskett P. European
Resuscitation Council Guidelines 2000 for Adult Advanced Life Support. A
statement from the Advanced Life Support Working Group and approved by the
Executive Committee of the European Resuscitation Council. Resuscitation
2001; 48:211-221.
4. Stiell IG, Hébert PC, Wells GA, et al. Vasopressin versus epinephrine
for inhospital cardiac arrest: a randomised controlled trial. Lancet 2001;
358:105-109.
Jerry Nolan
Chairman, Advanced Life Support Working Group
David Gabbott
Chairman, Advanced Life Support Course Subcommittee
Sarah Mitchell
Director
Robert Bingham
Chairman
Resuscitation Council,
5th Floor, Tavistock House North,
Tavistock Square
London
Competing interests: No competing interests
The recent review of Emergency Medicine (1)does not address a number
of other positive initiatives to resolve the situation of inappropriate
referral and "access" block.The author has suggested expanding existing
non functional systems such as increasing beds and enlarging Emergency
Departments (ED) which may only partially relieve the problem.
A number of other strategies to improve the situation have been trialled
in South West Sydney. These systems work as complimentary services to ED
and are based on improving communication with General Practitioners and
other healthcare workers and providing a range of alternative paths for
patients with acute conditions.
These strategies include an after hours general practice on the hospital
site with experienced GPs working on a roster system every evening ,and
direct referral from GP or ED to an ambulatory care service with 24 hour 7
day per week specialist on call(2).Moderate to low acuity patients may be
referred to these services and offer an alternative to hospital
admission.A responsive primary health nursing service is also available to
target patients attending ED and at risk of representation.
This approach involving multidisciplinary and multifaceted community care
,improved GP hospital communication and integration with ED provides many
other satisfactory care options and better utilisation of stretched
Emergency Department resources.
1.Fatovitch D,Emergency Medicine ,BMJ.2002;324:958-962
2.Wison S ,Chapmn C,Nancarrow L,Collins J,Macarthur Model for Ambulatory
Services,Aust Health Review.2001;24.2:187-193.
Competing interests: No competing interests
Sir
Fatovich highlights the important international problem of
overcrowding in emergency departments (ED) [1]. He also highlights a
common cause being the decreased availability of in patients beds. It has
long been recognised that the risk of waits is proportional to the average
bed occupancy in a hospital. In the UK, it is now recognised that
excessively high bed occupancy (over 85% [2] ) is not a sign of efficient
management but a sign of failure to plan.
In a review of emergency medicine, it is disappointing that he only
suggests 2 long term measures to address overcrowding. Although increasing
the number of beds should decrease overcrowding, it has to be combined
with a bed management system, working across elective and emergency
components, to ensure that average bed occupancy is kept at 82-85% (this
may require an extra 10,000 beds in England)
Overcrowding in EDs can only be solved by measures across the whole
health community. In the prehospital phase, systems must be in place to
avoid unnecessary attendance at the emergency department ( e.g. easy
availability of urgent primary care, ambulance services have protocols to
discharge patients to take to a variety of destinations, access to urgent
specialist clinics). Although some suggest that it is better to adapt the
ED system and creating new routes may increase total work [3]
In the emergency department, patient flows must be optimised to avoid
delay ( e.g. by streaming of patients), adequate staff of appropriate
seniority and training must be available, staff must be used to maximum
benefit ( e.g. by matching staffing levels and workload by the hour,
autonomous practice by nurse practitioners) and diagnostics must be
easily available at all times. Early senior input has been shown to
decrease unnecessary admissions. Various community link schemes, e.g. for
DVT, COPD, have reduced numbers needing a hospital bed. Within the
hospital, teams must ensure regular review of all patients with processes
to avoid delays in investigations and delay in discharge. Social care and
primary care must be adequately resourced and designed to enable safe
early discharge.
If a motorway becomes a car park at rush hour, the solution is not
just to add some more lanes, you need to look at flows on and off the
motorway and look at the whole transport infrastructure. The principles
are the same in the overcrowded emergency department and are part of the
recent UK government strategy- Reforming Emergency Care [4].
Matthew Cooke
Senior Lecturer in Emergency Care, University of Warwick, UK
A&E Advisor, Department of Health, UK.
1. Fatovich DM. Recent developments Emergency medicine. BMJ
2002;324:958-962
2. Bagust A. Place M. Posnett JW. Dynamics of bed use in accommodating
emergency admissions: stochastic simulation model. BMJ. 319(7203):155-8,
1999 Jul 17.
3. New Zealand Health Technology assessment. Emergency Department
Attendance: a critical appraisal. NZHTA report 8. 1998
4. Reforming Emergency Care. Dept of Health 2001.
www.doh,gov.uk/capacityplanning/reform.htm
Competing interests: No competing interests
Dear Sir,
With interest we read the review of Fatovich.(1) In Holland we have
recently published a prospective study concerning the transferal of
patients from an emergency department to other hospitals due to a shortage
in healthcare capacity.(2) One third of the acute surgical admissions had
to be refused either by telephone on the first telephone contact with
family practitioner, or transferred to an other hospital from our
emergency department. This is especially a problem in the elderly patients
with pre-existing morbidity, such as patients with a proximal femur
fracture, the so-called "bed-blockers". These patients usually cannot
return to their homes, and are on the waiting list for a nursing home. Due
to the shortage in nursing staff in nursing homes these “bed-blockers”
stay at wards of general hospitals much longer than actually needed, after
they have been operated upon.
Residents spent a lot of time on the telephone in the emergency department
to find a place for a patient in another hospital, sometimes as far as
Belgium. To transfer a patient with a proximal femur fracture a mean time
of 97 minutes telephone conversation was needed, for a cerebrovascular
accident even 129 minutes. Often the hospital of acceptance needed to be
assured that the patient could be send back to the hospital of transferal
after the operation due to the fear to admit a bed-blocker. This resulted
in a large amount of unnecessary patient transports.
In Amsterdam, The Netherlands, the shortage in nursing staff is the main
problem in general or academic hospitals hence often only 65% of the
available beds are used. Therefore, we like to use the term “lack of
nurses” instead of “lack of beds”!
The abstract of our paper is included as addendum to this letter.
Sincerely yours,
Rudolf W. Poolman MD (AMC, email: poolman@trauma.nl)
Jan B.F. Hulscher MD (St Lucas Anderas Hospital)
Hub J. Noten MD (St Lucas Andreas Hospital)
E. Philip Steller MD PhD (St Lucas Andreas Hospital)
References
1. Fatovich DM. Recent developments Emergency medicine. BMJ
2002;324:958-962
2. Poolman RW, Hulscher JBF, Noten HJ, Steller EPh. Insufficient
healthcare capacity for patients requiring immediate admission; a
prospective study in a general hospital in Amsterdam, March-November 2001
(Article in Dutch). Nederlands Tijdschrift voor Geneeskunde 2002; 15; 719-
722
ABSTRACT(2)
Insufficient healthcare capacity for patients requiring immediate
admission; a prospective study in a general hospital in Amsterdam, March-
November 2001
Objective. To gain insight into the shortage in healthcare capacity
for patients who require immediate admission to hospital.
Design. Prospective, descriptive.
Method. During the period 1 March-30 November 2001, data were collected on
all patients presenting at the casualty department at the Sint Lucas
Andreas Hospital in Amsterdam, the Netherlands, who had a surgical,
internal medicine or neurological condition which required immediate
admission and who could not be admitted due to a shortage in healthcare
capacity. The following data were registered: date of transfer, age,
gender, diagnosis, referring specialty, time of telephone call, accepting
hospital and time of acceptance. During the same period, the surgery
department also noted details of patients requiring immediate admission or
transfer whom they turned away after presentation via the telephone by
either the general practitioner or a different hospital.
Results. 131 patients could not be admitted, 68 men and 63 women with a
mean age of 69 years. The distribution across the specialties was as
follows: surgery: 63 patients (48%; mean age: 68 years); internal
medicine: 48 patients (37%; 65 years); neurology: 20 patients (15%; 74
years). The most common reasons for admission were proximal femur
fractures (24; 18%) and gastrointestinal disorders (27; 21%). Mean
duration from making the telephone call until acceptance elsewhere was 70
min (range: 1-330) for surgery, 42 min (5-180) for internal medicine and
116 min (10-870) for neurology. The transfer of patients with proximal
femur fractures (97 min) and cerebrovascular accident (129 min) took the
longest. During the same period, 170 patients were refused by the
department of surgery for first-time admission or transfer.
Competing interests: No competing interests
This article is a useful summary of the main issues facing providers
of hospital emergency services. It echoes many of the conclusions of a
Report on Accident & Emergency Services in the Republic of Ireland.
The Report was published by Comhairle na nOspideal - a statutory body
which regulates consultant and specialist registrar appointments and
advises the Minister for Health on hospital services in Ireland. Among its
recommendations are proposals for the division of hospital services into
three streams - emergency, elective and ambulatory; the use of common
triage processes, the provision of minor injury units, improved access to
diagnostics, better bed management and the appointment - subject to
organisational and contractual change - of 53 additional Consultants in
Emergency Medicine.
The Report also proposes that Emergency services be organised
regionally and that a number of hospitals act as Regional Emergency
Departments. Such Regional Departments would be staffed by teams of 4 - 7
consultants.
Currently, there are 21 permanent consultant posts in Emergency
Medicine in Ireland.
The Report is available for download at: http://www.comh-n-
osp.ie/policies/pol_set.html
Competing interests: No competing interests
Role of homeless and uninsured patients in overcrowded Emergency Departments
An Emergency Department (ED) is the only place in the current health
system where no patient is refused care. This clinical care is available
twenty four hours a day and seven days a week. Overcrowding is becoming a
big emergency health care delivery problem. Apart from the increased
financial burden, factors such as the increasing number of patients,
changing patient attitudes, increasing number of uninsured and homeless
people with diverse education levels play a big role in the overcrowding
of Emergency Departments.
The definition of what really is a health emergency is very relative
for the patient as well as the physician. For any patient who comes to an
Emergency Department (ED) his or her current complaint is an Emergency.
The symptom could range from loss of sleep to acute chest pain. It is the
prerogative of the attending ED physician to stratify this problem and
tackle it.
Today it is becoming increasingly difficult for health care set ups
to cater to the increase demand in Emergency Care. Evolving Diagnostic and
monitoring technologies have enhanced the protocols for evidence based
medicine which is a added contributor to the increase time spent by
patients in the ED. Hospitals have started to cut down beds because of
shortage of nurses. This has reflected on increased patient back up in
Emergency Departments. Concurrently the number of EDs is not growing. (1)
With the sulking global economy the issue of getting proper health
insurance does not take precedence over fulfilling daily needs. The only
place in the health system where insurance status is not a factor to
access care is the use of the services at a local ED. All these collage of
factors have been partial contributors to ED overcrowding.
For uninsured and homeless populations the ED serves as an easily
approachable option when it comes to food, shelter and care. It is not
rare to see homeless people arriving at the ED during winter with medical
complaints which will definitely get them shelter and warmth. There has
been a great increase in the number of homeless and the number of
uninsured people in the US. Current data gathered from the US Census
Bureau showed that the number of uninsured in the US increased from 41.2
million in 2001 to 43.6 million in 2002. This may be because of the
fractured economy resulting in loss of jobs and decrease in quality of
life. (2)
A community based interview study of 2578 homeless and marginally
housed persons showed that unstable housing, victimization, repeated
arrests, physical and mental disorders, as well as substance abuse acted
as forces to drive increased usage of EDs. This study highlighted the need
to reduce emergency department use among the homeless by targeting
identified risk factors on a public health level. (3)
A randomized trial studying compassionate care for the homeless in an
emergency department found that rates of ED use were high, with patients
making an average of seven visits per year. Moreover one third of the
patients made two or more visits within two days of the last visit. This
study additionally suggested that compassionate management in ED would
avoid return visits by homeless patients. (4)
Another study analyzing preferences for sites of care among urban
homeless and housed poor adults showed that lack of health insurance had
lead to an increase in the use of a non-ambulatory-care site. 28.9% of the
sample chose the ED. (5)
The problem of overcrowding in ED is a complex one. Economics, public
health and population constitution play a major role in combating this
issue. Receding rates of insured populations and increased rates of ED
utilization by the uninsured homeless are additional contributors which
need an integrated emergency public health intervention.
References:
1. Strategies to Alleviate Overcrowded Hospital Emergency
Departments. The American College of Emergency Physicians and The American
Hospital Association. www.acep.org/search
2. State Coverage Initiatives. Who are the Uninsured in the US.
http://www.statecoverage.net/who.htm
3. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency
department use among the homeless and marginally housed: results from a
community-based study. Am J Public Health. 2002 May; 92(5):778-84.
4. Redelmeier DA, Molin JP, Tibshirani RJ. A randomised trial of
compassionate care for the homeless in an emergency department. Lancet.
1995 May 6; 345(8958):1131-4.
5. O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Preferences for sites
of care among urban homeless and housed poor adults. J Gen Intern Med.
1999 Oct; 14(10):599-605.
Competing interests:
None declared
Competing interests: No competing interests